For Medicare, organizations may obtain exclusion information from any of the NCQA acceptable sources. |
HP 2025
FAQ Directory: Long-Term Services and Supports Distinction for Health Plans
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12.16.2024 NPDB Acceptable Source for Medicare and Medicaid Exclusions Is the NPDB an acceptable source for Medicare and Medicaid exclusions?
12.16.2024 Reviewer Names on Denial and Appeal Notifications Does NCQA require names or signatures of the reviewers on UM denial and appeal notifications?
12.16.2024 Sources for Medicare Sanctions Are organizations required to verify Medicare sanctions from all of the following sources?
• AMA Physician Master File.
• FSMB.
• NPDB.
• SAM.gov.
12.16.2024 MMP Plans CMS intends to dissolve Medicare-Medicaid Plan (MMP) contracts in 2026. Will that change product line rules for Accreditation?
11.15.2024 Verification of Medicare and Medicaid Sanctions and Exclusions Are organizations only required to verify Medicare and Medicaid sanctions and exclusions for practitioners who only provide services for members in the organization’s Medicare and Medicaid product lines?
10.15.2024 Hurricanes and other Natural Disasters Does NCQA make accommodations for organizations that have been impacted by a natural disaster and experienced a disruption in operations?
NCQA makes disaster accommodations on a case-by-case basis during the accreditation survey process.
The organization must document the events from the disaster that prohibited your organization from meeting the standard/element. During the accreditation survey, the surveyor will document all findings which will be reviewed by our Review Oversight Committee (ROC) to determine if any accommodations or exceptions should be granted.
The organization should communicate with the assigned ASC if accommodations are requested.
HP 2025
10.15.2024 QI 3: Number of Measures Required for Improvement Plan How many measures must an organization include in an improvement plan for QI 3, Elements C and D?
For Health Plan Accreditation 2025, the organization is only required to take action on one measure for Health Plan Ratings for which it received a 0 or 1 for QI 3, Element C, and one measure required for QRS in QI 3, Element D. However, if the organization chooses to address more than one measure in its improvement plan, the guidance regarding using one action to address all measures applies but NCQA will only score taking action on one measure for the 2025 standards year.
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10.15.2024 Eligibility for NA for QI 3 My organization did not receive a Health Plan Rating (HPR) scoresheet. How will my organization be scored in QI 3 for a Renewal Survey?
For commercial, Medicare and Medicaid organizations to be able to calculate an average rating for QI 3, Element B, they must receive a Health Plan Ratings scoresheet. Only organizations that have complete data receive a rating and scoresheet. Therefore, organizations that do not receive an HPR scoresheet will be scored NA in QI 3, Elements B and C.
The organization must demonstrate that it meets the requirements in QI 3, Element A, and will not be eligible for NA for that element.
Similarly, if an Exchange organization either does not report QRS data to CMS or receives NR for the Exchange product line because it does not have a valid rate for any required QRS measure in Element D, it must demonstrate data exchange in QI 3, Element A.
HP 2025
8.15.2024 Retroactive Changes to System Controls Standards NCQA posted a memo with changes to the NCQA Accreditation Standards for the 2024 and 2025 Standards Years indicating that organizations are no longer required to describe their process for system controls monitoring or their auditing methodology in their policies and procedures (e.g., UM 12, Element A, factor 7 in HPA is scored NA). Does this mean organizations are no longer required to monitor their UM and CR system controls as required in the oversight elements (e.g., UM 12, Element B in HPA)?
No. Organizations are still required to monitor for system controls. The NA for the system controls policies and procedures requirement (e.g., UM 12, Element A, factor 7, in Health Plan Accreditation) does not affect an organization’s ability to meet the corresponding system controls monitoring requirement (e.g., UM 12, Element B in Health Plan Accreditation); it means the organization is not required to describe the monitoring process in its policies and procedures, but must monitor that its systems are protecting data from unauthorized modifications. Also, as noted in “Related information” in the monitoring requirements (e.g., UM 12, Element B in Health Plan Accreditation), NCQA only reviews specific components for monitoring (e.g., for UM, NCQA reviews that the organization monitored receipt and notification dates).
Note: The referenced memo is on the NCQA website at https://www.ncqa.org/wp-content/uploads/2025-Retroactive-Changes-Memo_Final.pdf. It applies to the 2024/2025 standards year only; no exceptions (NA scores or other changes) will be made for the 2023 or prior standards years. Surveys conducted on standards prior to 2024 standards will be reviewed and scored accordingly; any corrective actions issued prior to the 2024 standards still apply
HP 2024
5.15.2024 Use of AI for UM Decisions May organizations use artificial intelligence to make medical necessity denial decisions or appeal decisions?
No. NCQA UM standards do not allow the use of AI to make medical necessity denial decisions, or any appeal decisions.
If an organization uses AI in the UM process, medical necessity review requires that denial decisions be made only by an appropriate clinical professional and appeal decisions require same-or-similar specialist review, as specified in the NCQA standards.
HP 2024
12.15.2023 Collaboration Between Medical Care and Behavioral Health Care Does collaboration between health plan staff clinicians meet the intent of the collaboration requirement in QI 4, Elements A and B?
Typically, no as health plan staff are not practicing practitioners within the health plan's network. The intent of collaboration requirements are for organizations to demonstrate collaboration between their behavioral healthcare delivery system (network practitioners) and medical care delivery system (network practitioners).
Note: Demonstrating collaboration with an MBHO is acceptable for the collaboration with “behavioral healthcare practitioners” component of the requirement.
HP 2024